Incidence and Neuropsychiatric Sequelae of Traumatic Brain

1
Incidence and Neuropsychiatric Sequelae of
Traumatic Brain Injury Implications for the
Military Deborah L. Warden, M.D National
Director Defense and Veterans Brain Injury
Center Armed Forces Epidemiological Board San
Diego, California November 2004
2
Talk Overview

• TBI Overview pathophysiology
• Mental Health Aspects of TBI
• Epidemiology
• Blast Injury
• Possible Areas of Research

3
Measurements of TBI Severity

• Length of loss of consciousness (LOC)
• Length of post-traumatic amnesia (PTA)
• Post-injury period of confusion with deficits in
  retaining new information and processing new
  memories PTA ends when continuous (or
  near-continuous) memory resumes
• Glasgow Coma Scale (GCS)

4
Neuropathology of Closed TBI

• Primary Injury
• Contusions/Hemorrhages
• Diffuse Axonal Injury (DAI)
• Secondary Injury (Intracranial)
• Blood Flow and Metabolic Changes
• Traumatic Hematomas
• Cerebral Edema
• Hydrocephalus
• Increased Intracranial Pressure

5
Neuropathology of Closed TBI

• Secondary Injury (Systemic), e.g.,
• Hypoxemia
• Hypotension
• Hyponatremia
• Infection

6
Diffuse Axonal Injury

• Axonal Stretching or Tearing
• Physiological Reaction (e.g., Povlishock, et al.
  1992)
• Impairment of axoplasmic transport, focal
  swelling of the axon, progression to axonal
  separation
• Potential window of opportunity before axon
  becomes discontinuous

7
Morbidity of TBI

• Cognitive, somatic, neuropsychiatric sequelae

8
Regional Cortical Vulnerability to TBI Predicts
Neuropsychiatric Sequelae
Dorsolateral prefrontal cortex (executive
function, including sustained and complex
attention, memory retrieval, abstraction,
judgement, insight, problem solving)
Orbitofrontal cortex (emotional and social
responding)
Anterior temporal cortex (memory retrieval, face
recognition, language)
Amygdala (emotional learning and conditioning,
including fear/anxiety)
Ventral brainstem (arousal, ascending activation
of diencephalic, subcortical, and cortical
structures)
Hippocampus (only partially visible in this view
- declarative memory)
D. Arcineagas, M.D.
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Postconcussion Symptoms (PCS)

• Headache
• Dizziness
• Irritability
• Decreased Concentration
• Memory Problems

• Fatigue
• Visual Disturbances
• Sensitivity to Noise
• Judgement Problems
• Anxiety
• Depression

10
Post Concussive Sx inMild TBI

• Natural history is recovery within weeks to
  months (Levin 1987), although a small percentage
  will continue to have persistent symptoms
  (Alexander, Neurology 1995)
• High school athletes with 3 or more prior
  concussions were up to 9 times more likely to
  develop symptoms than athletes without prior
  injury (Collins, et al, Neurosurgery 2004)
• Patients with MTBI may be more sensitive to
  symptoms/dysfunction than their families
  patients with moderate-severe TBI are less
  sensitive to dysfunction than their families
  (Drake, et al, unpublished data)

11
Average Number of Post TBI Symptoms by Severity
of Injury Ft. Bragg (For those reporting on 20
or more of the 22 symptoms)
12
Neurocognitive Changes

• Attention/Concentration
• Speed of Mental Processing
• Learning/Information Retrieval
• Executive Functions (e. g., Planning, Problem
  Solving, Self Monitoring) May see judgment
  problems, apathy, inappropriate behaviors

13
fMRI study of MTBI and Memory (McAllister, et
al, 2000)
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USMA Concussion Study
15
Simple Reaction Time
p lt 0.05
Baseline
1 hour post
4 days post
Warden D, Bleiberg J, Cameron K, et al,
Neurology, 2001
16
ConcussionTime to Recovery
Bleiberg J., et al. Neurosurgery, 2004.
17
Psychological/Psychiatric and Psychosocial
Changes after TBI

• Personality
• Increased/Decreased Activation
• Episodic DyscontrolIrritability
• Psychiatric
• Mood Disturbance
• Psychosis
• Psychosocial
• Work Status
• Relationships with others

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Depression and TBI

• Approximately 33 of hospitalized TBI patients
  develop Major Depression in 1st year (Jorge et al
  2004)
• 25-60 of TBI patients develop a depressive
  episode within 8 years of injury (Kreutzer, 2001
  Hibbard, et al, 1998 Jorge and Robinson, 2002).
• Depression is associated with comorbid anxiety,
  aggressive behavior, poorer social and functional
  outcome (Jorge and Robinson, 2002 Jorge et al
  2004) and left frontal brain injury Jorge et al
  2004).

19
PCS and Acute Stress/ Post Traumatic Stress
Disorder (PTSD)

• Overlap of symptoms
• Consideration that some patients with battle
  fatigue/shellshock may have had repeat
  concussions
• Issue of PTSD in individuals with LOC
• Consecutive series of military subjects with
  moderate-severe TBI, six of 47 (13) met all
  criteria of PTSD except for the
  intrusive/reexperiencing phenomena (Warden, et
  al. 1997).
• 
  
• 
  

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PTSD in TBI

• Studies suggest that PTSD following TBI does
  occur, but may be modified by the brain injury.
• Intrusive memories are less common than in
  non-TBI individuals when present, highly
  predictive of PTSD development of PTSD is more
  likely in less severely injured individuals with
  TBI.
• The rate of PTSD appears to increase over time,
  though few studies offer longitudinal follow-up.
  
• Range of traumatic memories events immediately
  before loss of consciousness, events experienced
  after regaining consciousness, information/photos
  etc. learned upon regaining consciousness, and
  traumas reactivated from earlier life events.
• Warden Labatte, PTSD and other Anxiety
  Disorders, Textbook of Traumatic Brain Injury,
  APPI, 2004

21
TBI Treatment

• Pharmacotherapy
• Symptomatic Treatment Headache, Sleep,
  Irritability
• Antidepressants (e.g., SSRIs) PTSD
• Stimulants
• Anticonvulsants/Mood Stabilizers
• Note Limited Class I evidence to date DVBIC
  RCTs in progress for SSRIs

22
TBI Treatment

• Psycho-educational
• TBI Symtomatology
• Expected Course of Recovery
• With acute intervention, results show reduced
  morbidity
• Rehabilitation
• More intensive TBI rehabilitation when needed for
  more severe injuries (either in specialized
  centers or with TBI specialists in DVA or
  military centers Salazar, et al., 2000)
• Note (Ponsford, et al., 2002 Mittenberg, et
  al., 1996 Bell, et al., J Head Trauma Rehabil,
  2004)

23
Traumatic Brain Injury (TBI) Epidemiology
Incidence
Incidence (cases/100,000)
From D. Hovda, UCLA BIRC Program (modified from
Kraus JF, et. al. 1996 and Durkin MS, et. al.
1998)
Age (years)
24
Military Hospital Costs for TBI in 1992
Hospital Costs Associated with TBI Among
Military Personnel, Dependents, and Retirees
42 million in FY 1992
Source Ommaya AK, Ommaya AK, Dannenberg AL,
Salazar AM. Causation, incidence, and costs of
traumatic brain injury in the U.S. Military
Medical System. J Trauma. 1996 40(2) 211-217.
25
Total Cost Associated with TBI in the Civilian
Population in 1985
Costs for treatment and other care 4.5
billion Costs resulting from lost work
and disability for TBI survivors 20.6
billion Costs such as lost income resulting from
TBI fatalities 12.7 billion
Sources Max W, MacKenzie EJ. Head injuries
Costs and consequences. J Head Trauma Rehabil.
1991 6(2) 76-91.
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Diagnoses Considered to be TBI
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Annual Incidence in Civilian Population
50,000 Deaths
235,000 Hospitalizations
1,111,000 Emergency Department Visits
??? Other Medical Care or No Care
Source Langlois, et al., CDC Traumatic Brain
Injury in the United States, October 2004
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Selected Demographics of Hospitalized TBI Patients

• 15 to 24 age group is among those at the highest
  risk for TBI in the military(2) and civilian
  populations1
• The TBI risk for civilian males is about 1.7
  times greater than for civilian females1. The
  TBI risk for military males is about 1.4 times
  greater than for military females (2).
• The TBI risk for military females is
  approximately the same as that of civilian males2

Sources 1. Langlois, et al., CDC. Traumatic
Brain Injury in the United States Emergency
department visits, hospitalizations, and
deaths. October 2004. 2. Ommaya AK, Ommaya AK,
Dannenberg AL, Salazar AM. Causation, incidence,
and costs of traumatic brain injury in the
U.S. Military Medical System. J Trauma. 1996
40(2) 211-217.
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Estimates of Untreated TBI Cases

• Sosin, Sniezek, and Thurman conservatively
  estimated from the 1991 National Health Interview
  Survey that 25 of TBI cases were medically
  untreated.

Brain injury was defined as self-reported head
injury with loss of consciousness that also
resulted in a period of restricted activity.
30
Missed TBI Diagnoses
51 of 47 patients seen in a British trauma
center with a TBI did not have a TBI diagnosis
recorded Most TBI patients lacking a coded TBI
diagnosis had other injuries coded
TBI defined as any injury to the head and some
gap in memory for events.
Moss NEG, Wade DT. Admission after head injury
How many occur and how many are recorded?.
Injury. 1996 27(3) 159-161.
31
Combat TBI

• Blast Induced Injury

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Blast Injuries

• Multifactorial injury mechanism
• Primary Direct exposure to overpressurization
  wave velocity gt/ 300m/sec (speed of sound in
  air)
• Impact from blast energized debris penetrating
  and nonpenetrating
• Displacement of the person by the blast and
  impact
• Burns/Inhalation of gases
• Combination with MVA in war theater
• G. Cooper, et al 1983

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Blast Injuries

• Primary blast injury interaction of the
  overpressurization wave and the body
• Air-filled organs vulnerable ear, lung, and GI
  tract
• The brain is also vulnerable direct injury, e.g.
  cerebral contusion indirect injury, e.g.
  cerebral infarction secondary to air emboli
  (Elsayed, 1997Mayorga, 1997). Data on non-fatal
  blast closed brain injury are limited.
• Blast injury induced brain injury resultant
  cognitive dysfunction are described in rats
  exposed to both whole body overpressurization
  waves, and also to more focal blasts to the torso
  while the head was protected (Cernak et al.,
  2001).

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Blast Injury Induced Brain Injury

• Research to date focused on injuries to
  extremities, torso, and penetrating head injuries
  (shrapnel/flying debris).
• Penetrating injuries typically identified and
  cared for immediately.
• Closed head injury, especially more mild
  injuries/concussions, may not be as readily
  identified, particularly if occurring with other
  injuries requiring immediate attention such as
  amputation.
• Cernak, I., et. al. 1999. J Trauma Injury,
  Infection, and Critical Care. 471 96-104

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ARMY OIF WOUNDED IN ACTION 19 Mar 03 31 May
04 N 1288
36
(No Transcript)
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ARMY OIF WIA BY SPECIALTY 19 Mar 03 31 May 04
N 1288
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Combat TBI in OIF The Walter Reed Army Medical
Center (WRAMC) Experience

• The Defense and Veterans Brain Injury Center at
  WRAMC has evaluated 355 TBI patients from OIF/OEF
  as of end Aug 2004.
• Over half of all WIA injuries currently sustained
  are blast related injuries (OTSG).
• 59 of blast patients seen at WRAMC had at least
  mild Traumatic Brain Injury
• Preliminary data demonstrate that as many
  soldiers are treated at a CSH for head injury and
  returned forward as evacuated out of theater.

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Implications of MTBI/Concussion

• Unit Readiness
• 100 msec. relatively large reaction time change
• soldiers may be unable to will away symptoms
• behavioral issues may ensue
• Individual Issues
• feel broken
• possible shell shock as repeat blast MTBI
  exposure
• irritability/ issues with family and others

40
WAR ON TERRORMilitary and Civilian Focus Merge

• Battlefield and Enemy are less defined
• Mass Casualty Preparedness at Home
• Limited time and rapid depletion of resources
• Triage dependent on salvagability vs. costs in
  time, resources and personnel

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DVBIC Blast TBI Initiatives

• Establish archives of individuals treated in
  theater
• QI projects Records of many in-theater docs to
  DVBIC
• Determine the size of the problem in returning
  units
• Capabilities within existing research protocols
• Ability to screen for injury/symptoms
• Post deployment questions
• Telemedicine capabilities for assessment
• Follow-up of individuals seen at WRAMC
• Assess factors related to poor outcome/ good
  outcome cumulative TBI

42
Take Homeson Military and Veteran TBI

• Need to screen all those at risk for TBI
• When these individuals are encountered
• Good history for identification and documentation
• Evaluation, including cognitive/behavioral and
  mood screens
• Access to care and follow-up ensured by DoD and
  VA
• www.dvbic.org

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Summary

• TBI in the current combat environment not
  uncommon, often in association with severe
  multi-trauma, PTSD, or underdiagnosed concussion
• Possible consequences
• Effects on unit readiness when service members
  prematurely returned to duty
• Lack of care can lead to increased morbidity
• Effective treatment requires identification of
  cases

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DVBIC Headquarters, WRAMC

• Warren Lux, MD
• Glen Parkinson, MSW
• Winston Punch, MA
• Alice Marie Stevens, MA
• Lorraine Goodrich, BA
• Laurie Ryan, PhD
• Karen Schwab, PhD
• Robert Sharpe, MPA
• Jose Valls, LPN
• Jehue Wilkinson, LPN
• Lauren Chandler, BA

• LTC R Armonda, MC
• Gayle Baker, MHS
• Stephanie Ball, BS
• Angela Bastolla, BS
• COL James Ecklund, MC
• Louis French, PsyD
• Kelly Gourdin, BS
• LTC Ed Hartmann
• Brian Ivins, MA
• Ronelle Inollado, RN
• LTC Geoff Ling, MC

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DVHIP/DVBIC

• Walter Reed AMC -Lou French, Psy D
• Naval Medical Center, San Diego
• CAPT John Grossmith, Angela Drake, PhD
• Wilford Hall AF Medical Center - LTC Michael
  Jaffe
• Tampa VAMC Steve Scott, DO
• Minneapolis VAMC Barbara Sigford, MD, PhD
• Palo Alto VAMC Elaine Date, MD Henry Lew, MD,
  PhD
• Richmond VAMC William Walker, MD
• Virginia Neurocare, Inc. George Zitnay, PhD